Steerable lesion excluding heart implants for congestive heart failure

ABSTRACT

Devices, systems, and methods for treating a heart of a patient may make use of one or more implant structures which limit a size of a chamber of the heart, such as by deploying a tensile member to bring a wall of the heart toward (optionally into contact with) a septum of the heart.

CROSS-REFERENCES TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.15/202,394, filed Jul. 5, 2016, which is a continuation of U.S.application Ser. No. 14/723,187, filed May 27, 2015, now U.S. Pat. No.9,402,722, which is a continuation of U.S. application Ser. No.13/794,096 filed Mar. 11, 2013, now U.S. Pat. No. 9,044,231, which is acontinuation of U.S. application Ser. No. 12/846,777, filed Jul. 29,2010, now U.S. Pat. No. 8,394,008, which is a continuation of U.S.application Ser. No. 12/033,641, filed Feb. 19, 2008, now U.S. Pat. No.7,785,248, which is a continuation of PCT Patent Application No.PCT/US2006/032663, filed on Aug. 21, 2006, which claims the benefit ofpriority from U.S. Provisional Application No. 60/709,730, filed Aug.19, 2005; the full disclosures of which are incorporated herein byreference in their entirety for all purposes.

BACKGROUND OF THE INVENTION

The present invention is generally directed to improved devices,systems, and methods for treatment of the heart. Exemplary embodimentsprovide implants and methods for alleviating congestive heart failureand other progressive diseases of the heart. Congestive heart failuremay, for example, be treated using one or more implants which isselectively positioned relative to a septum and wall of the heart so asto exclude scar tissue and limit a cross section across a ventricle.

Congestive heart failure (sometimes referred to as “CHF” or “heartfailure”) is a condition in which the heart does not pump enough bloodto the body's other organs. Congestive heart failure may in some casesresult from narrowing of the arteries that supply blood to the heartmuscle, high blood pressure, heart valve dysfunctions due to rheumaticfever or other causes, cardiomyopathy (a primary disease of the heartmuscle itself), congenital heart defects, infections of the hearttissues, and the like. However, in most cases congestive heart failuremay be triggered by a heart attack or myocardial infarction. Heartattacks can cause scar tissue that interferes with the heart muscle'shealthy function, and that scar tissue can progressively replace moreand more of the heart tissue. More specifically, the presence of thescar may lead to a compensatory neuro-hormonal response by theremaining, non-infarcted myocardium.

People with heart failure may have difficulty exerting themselves, oftenbecoming short of breath, tired, and the like. As blood flow out of theheart slows, blood returning to the heart through the vascular systemdecreases, causing congestion in the tissues. Edema or swelling mayoccur in the legs and ankles, as well as other parts of the body. Fluidmay also collect in the lungs, interfering with breathing (especiallywhen lying down). Congestive heart failure may also decrease the abilityof the kidneys to remove sodium and water, and the fluid buildup may besufficient to cause substantial weight gain. With progression of thedisease, this destructive sequence of events can cause the eventualfailure of the remaining functional heart muscle.

Treatments for congestive heart failure may involve rest, dietarychanges, and modified daily activities. Various drugs may also be usedto alleviate detrimental effects of congestive heart failure, such as byexpanding blood vessels, improving and/or increasing pumping of theremaining healthy heart tissue, increasing the elimination of wastefluids, and the like.

Surgical interventions have also been applied for treatment ofcongestive heart failure. If the heart failure is related to an abnormalheart valve, the valve may be surgically replaced or repaired.Techniques also exist for exclusion of the scar and volume reduction ofthe ventricle. These techniques may involve (for example) surgical leftventricular reconstruction, ventricular restoration, the Dor procedure,and the like. If the heart becomes sufficiently damaged, even moredrastic surgery may be considered. For example, a heart transplant maybe the most viable option for some patients. These surgical therapiescan be at least partially effective, but typically involve substantialpatient trauma. While people with mild or moderate congestive heartfailure may benefit from these known techniques to alleviate thesymptoms and/or slow the progression of the disease, less traumatictherapies which significantly increase the heart function and extendlife of congestive heart failure patients has remained a goal.

It has recently been proposed that an insert or implant be placed in theheart of patients with congestive heart failure so as to reduceventricular volume. With congestive heart failure, the left ventricleoften dilates or increases in size. This can result in a significantincrease in wall tension and stress. With disease progression, thevolume within the left ventricle gradually increases and blood flowgradually decreases, with scar tissue often taking up a greater andgreater portion of the ventricle wall. By implanting a device whichbrings opposed walls of the ventricle into contact with one another, aportion of the ventricle may be constricted or closed off. By reducingthe overall size of the ventricle, particularly by reducing the portionof the functioning ventricle chamber defined by scar tissue, the heartfunction may be significantly increased and the effects of diseaseprogression at least temporarily reversed, halted, and/or slowed.

An exemplary method and implant for closing off a lower portion of aheart ventricle is shown in FIG. 1, and is more fully described in U.S.Pat. No. 6,776,754, the full disclosure of which is incorporated hereinby reference. As illustrated in FIG. 1, a patient's heart 24 has beentreated by deployment of an implant across a lower portion of the leftventricle 32 between septum 28 and a left wall or myocardium region 34.The implant generally includes a tensile member which extends betweenanchors 36 and 38.

A variety of alternative implant structures and methods have also beenproposed for treatment of the heart. U.S. Pat. No. 6,059,715 is directedto a heart wall tension reduction apparatus. U.S. Pat. No. 6,162,168also describes a heart wall tension reduction apparatus, while U.S. Pat.No. 6,125,852 describes minimally-invasive devices and methods fortreatment of congestive heart failure, at least some of which involvereshaping an outer wall of the patient's heart so as to reduce thetransverse dimension of the left ventricle. U.S. Pat. No. 6,616,684describes endovascular splinting devices and methods, while U.S. Pat.No. 6,808,488 describes external stress reduction devices and methodsthat may create a heart wall shape change. Each of these patents is alsoincorporated herein by reference.

While these and other proposed implants may help surgically remedy thesize of the ventricle as a treatment of congestive heart failure andappear to offer benefits for many patients, still further advances wouldbe desirable. In general, it would be desirable to provide improveddevices, systems, and methods for treatment of congestive heart failureand other disease conditions of the heart. It would be particularlydesirable if such devices and techniques could increase the overalltherapeutic benefit for patients in which they are implanted, and/orcould increase the number of patients who might benefit from theserecently proposed therapies. Ideally, at least some embodiments wouldinclude structures and or methods for prophylactic use, potentiallyaltogether avoiding some or all of the deleterious symptoms ofcongestive heart failure after a patient has a heart attack, but beforeforeseeable disease progression. It would be advantageous if theseimprovements could be provided without overly complicating the deviceimplantation procedure or increasing the trauma to the patientundergoing the surgery, ideally while significantly enhancing thebenefits provided by the implanted device.

BRIEF SUMMARY OF THE INVENTION

The present invention generally provides improved devices, systems, andmethods for treating a heart of a patient. Embodiments of the inventionmay make use of structures which limit a size of a chamber of the heart,such as by deploying one or more tensile member to bring a wall of theheart and a septum of the heart toward each other (and often intocontact). Therapeutic benefits of the implants may be enhanced byimage-guided steering of the implant within the ventricle betweenpenetration of the septum and wall. A plurality of tension members mayhelp exclude scar tissue and provide a more effective remainingventricle chamber. The implant may optionally be biodegradable, with theapproximated surfaces of the septum and wall treated so as to induce theformation of adhesions. Antiproliferative agents or other drugs may beeluted from the implant to limit detrimental tissue responses andenhance the benefits of the implants for treatment of congestive heartfailure and other disease states of the heart. Embodiments of thisinvention relate to devices and methods for completely off-pumptreatment of congestive heart failure patients, particular sizingdevices and methods for excluding infracted tissue and reducingventricular volume. Some of the devices and methods described herein maybe performed thoracoscopically off-pump and may be less traumatic to thepatient than open chest and open heart surgical techniques.

In a first aspect, the invention provides a method for treating a heart.The heart has a first chamber bordered by a septum and a wall. The heartalso has a second chamber that is separated from the first chamber bythe septum. The method comprises penetrating the septum at a firstlocation selected for deployment of an implant. The wall is penetratedat a second location selected for the deployment of the implant, withcontrolled steering being provided between the first location and thesecond location with reference to an image of the first chamber. Theimplant is deployed by affixing a first anchor of the implant adjacentthe penetration of the septum, and a second anchor of the implantadjacent the penetration of the wall. Tension is applied between thefirst and second anchor.

The wall will often be penetrated at additional locations, with thetension being applied between the septum and the wall by a plurality oflaterally offset tension members. While the tension members may becoupled to each other in some embodiments (such as by angling away fromeach other or the like), in most embodiments each implant will have itsown associated anchors and tension member.

The tension members will generally bring the wall and septum intoengagement, and the separation between the tension members will allowthe engagement to extend across at least a portion of the chamber. Thisengagement can effectively exclude regions of the wall and septum fromthe left ventricle. The anchors may extend laterally along the septum orwall towards each other (for example, having a width as measuredextending toward an adjacent anchor that is greater than a height). Thepattern of implants and anchors will generally be arranged to leave aremaining effective chamber that approximates the shape of a healthyheart chamber, avoids excessive thrombus-accumulating voids, andprovides good effective pumping of blood therethrough.

In many embodiments, tissue near the first or second location may beengaged and characterized by a probe. If the characterized tissue doesnot appear suitable for formation of the penetration, the probe may berepositioned at a more suitable location. For example, a probe having adistal electrode surface may be advanced into contact with the tissue,and a pacing signal can be transmitted from the electrode. If the pacingsignal is directly coupled to healthy, contractile heart tissue, theprobe has effectively characterized the engaged tissue. As it may bedesirable for the penetration to be formed in healthy tissue in someembodiments, engaged tissues which are not effectively paced by theapplied signal may not be suitable for locating the anchor. In otherembodiments, it may be desirable for the penetration to be formed inscar tissue which is not as susceptible to pacing, so that the implantmay not fully exclude all scar tissue from the effective chamber. Ineither case, tissue characterization may help improve accuracy overdeployment of the implant and efficacy of the therapy. The probe maycomprise a perforation device, and may also be used to perforate thecharacterized tissue such as by energizing a bullet-shaped electrodesurface of a steerable perforation device with electrosurgical energy.

The anchors will often be affixed by radially expanding the anchors andengaging axially-oriented surfaces of the anchors with tissue adjacentthe perforations. For example, one or more of the anchors may comprise aplurality of arms defined by axial cuts in a tube. Radial expansion ofthe anchors may be effected by bending the arms radially outwardly, withthe axially oriented surface comprising a first portion of each arm thatextends perpendicular to the axis of the tube, and which is supported bya longer angled portion of the arm. In some embodiments, theaxially-oriented surface may be supported by introducing a fluid intothe anchor, with the fluid often being restrained by a bladder materialsimilar to a balloon of a catheter balloon. Such a bladder may be usedto support radially expanding arms as described above, or may be used asan anchor by itself. The axially oriented surface does not necessarilyhave to be parallel to the axis of the tension member, and may angleradially outwardly while still providing sufficient axial tissueengagement for anchoring. The fill material may harden, reversibly orirreversibly, within the anchor. In some embodiments, the implant mayrelease a bioactive material, such as by including a drug-elutingcoating on at least a portion of the implant, by including pores in thebladder anchor which allow transmission of the bioactive agent fromwithin the fill material, or the like. The agent may inhibit cellproliferation, enhance adhesion formation, and/or the like.

To promote formation of adhesions, a region of the endocardium borderingthe first chamber may be treated by subjecting the region to mechanicalinjury, by applying electrical, laser, or some other energy, by applyingan appropriate agent or compound, or the like. Where adhesions arepromoted or otherwise affix the septum and wall to each other, theimplant may biodegrade or be removed with scar tissue remainingeffectively excluded from the chamber.

The tension may be applied between the anchors by decreasing a length ofa tension member. As a result, a portion of the tension member mayextend through the wall so as to remain in an extra-cardiac space. Ingeneral, the implant may be introduced through the wall and septum usinga minimally invasive intraluminal approach, a minimally invasiveendoscopic approach, an open surgical approach to the heart, or acombination of two or more of these methods. The image used forreference during deployment of the implant may be obtained usingintracardiac echocardiography, extra-cardiac echocardiography,endoscopy, fluoroscopy, or the like. Preferably, the implant and/ordelivery system components associated therewith will provide highcontrasts within the image.

In another aspect, the invention provides a system for treating a heart.The heart has a first chamber bordered by a septum and a wall. The hearthas a second chamber separated from the first chamber by the septum. Thesystem comprises a plurality of implants. Each implant has an anchor, awall anchor, and a tension member to apply tension between the septumand wall when the implant is deployed so as to bring the wall and septuminto engagement. The implants together are configured to extend theengagement across a portion of the chamber (or all of the chamber)sufficiently to effectively exclude regions of both the wall and septumfrom the chamber.

In another aspect, the invention provides a system for treating theheart. The heart has a first chamber bordered by a septum and a wall,and a second chamber separated from the first chamber by the septum. Thesystem comprises an implant having a septum anchor, a wall anchor, and atension member to apply tension between the septum and wall when theimplant is deployed so as to bring the septum and wall into engagement.A deployment catheter releasably supports at a least a portion of theimplant for deploying the implant in the heart. The deployment cathetercomprises or receives a tissue identifier for characterization of atissue of the first chamber.

In another aspect, the invention provides a system for treating a hearthaving a first chamber bordered by a septum and a wall, and a secondchambered separated from the first chamber by the septum. The systemcomprises an implant having a septum anchor, a wall anchor, and atension member to apply tension between the septum and wall when theimplant is deployed so as to bring the wall and septum into engagement.At least one of the anchors has a small profile insertion configurationand large profile deployed configuration. The at least one anchor isradially expandable from the small profile configuration to the largeprofile configuration in situ so that an axially-oriented surface of theat least one anchor can anchor the implant to tissue of the heart.

In yet another aspect, the invention provides a system for treating aheart having a first chamber bordered by a septum and a wall, and asecond chambered separated from the first chamber by the septum. Thesystem comprises an implant having a septum anchor, a wall anchor, and atension member to apply tension between the septum and wall when theimplant is deployed so as to bring the septum and wall into engagement.A deployment catheter releasably supports at least a portion of theimplant for deployment of the implant in the heart. The deploymentcatheter comprises or receives an adhesion inducing surface fordirecting energy or a material toward a region of the endocardiumbordering the first chamber. The material or energy induces adhesionsalong the region. The tension is applied so as to approximate the walland septum along the region.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a cross-sectional view schematically illustrating a knownimplant and method for closing off a lower portion of a heart ventricle,as described in the background section.

FIG. 2 schematically illustrates a side view of the lower portion of theheart, showing how three implants together reduce the effective size ofthe left ventricle by effectively excluding a region of scar tissue fromthe septum and left ventricle wall.

FIGS. 2A and 2B schematically illustrate deployment of three laterallyoffset implants to effectively exclude a portion of the left ventricle.

FIGS. 2C and 2D schematically illustrate a single implant having threelaterally offset tension members for effectively excluding a region ofscar tissue from the left ventricle.

FIGS. 3A and 3B illustrate examples of images of the heart and/ordevices disposed therein that may be used to direct deployment ofembodiments of the invention.

FIGS. 4A-4E are cross-sectional views schematically illustrating methodsfor accessing, identifying, and penetrating tissues for deployment ofthe implant system of FIGS. 2 and 2A.

FIGS. 5A and 5B are cross-sectional views schematically illustratinginitial deployment of an implant of the system of FIGS. 2A and 2B, withthe implant initially being deployed in an elongate configuration.

FIGS. 6A-6D illustrate deployment of an anchor for use in the implant ofFIG. 5B.

FIGS. 7A and 7B are cross-sectional views schematically illustratingshortening of the tensile member of FIG. 5B from the elongate initialconfiguration to a shortened deployed configuration so as to reduce asize of the left ventricle and effectively exclude at least a portion ofa scar tissue from the left ventricle.

FIG. 8 schematically illustrates an alternative anchor structure in theform of a inflated balloon, an annular balloon disposed within a wall ofthe left ventricle so as to inhibit bloodflow through a perforation, andtreating a myocardial tissue surface with mechanical energy from a buror the like to promote adhesion formation.

FIG. 9 schematically illustrates accessing the heart via a subxiphoidincision.

FIG. 10 illustrates a method for unloading of the heart with a doubleballoon catheter.

FIGS. 11A-11C schematically illustrate one variation of atransventricular implant and anchor system from a left ventricularapproach.

FIGS. 12A and 12B schematically illustrate another variation of atransventricular implant and anchor system from a right ventricularapproach.

FIG. 13 illustrates a double balloon catheter for unloading of the heartin the method of FIG. 10.

FIGS. 14A-14C schematically illustrate another variation of atransventricular implant and anchor system from a left ventricularapproach.

DETAILED DESCRIPTION OF THE INVENTION

The present invention generally provides improved devices, systems, andmethods for treatment of a heart. Embodiments of the invention may beparticularly beneficial for treatment of congestive heart failure andother disease conditions of the heart. The invention may find uses as aprophylactic treatment, and/or may be included as at least a portion ofa therapeutic intervention.

Myocardial infarction and the resultant scar formation is often theindex event in the genesis of congestive heart failure. The presence ofthe scar may, if left untreated, lead to a compensatory neuro-hormonalresponse by the remaining, non-infarcted myocardium. The systems,methods, and devices described herein may be applied to inhibit,reverse, or avoid this response altogether, often halting a destructivesequence of events which could otherwise cause the eventual failure ofthe remaining functional heart muscle.

Embodiments of the present invention may build on known techniques forexclusion of the scar and volume reduction of the ventricle. Unlikeknown techniques that are often accomplished through open surgery,including left ventricular reconstruction, ventricular restoration, theDor procedure, and the like, the treatments described herein will often(though not necessarily always) be implemented in a minimally invasivemanner. Embodiments of the invention can provide advantages similar tothose (for example) of surgical reconstruction of the ventricle,resulting in improved function due to improved dynamics, and bynormalizing the downward cycle initiated by the original injury andmediated by the neuro-hormonal disease progression response.

Advantageously, the methods, devices, and systems described herein mayallow percutaneous left ventricular scar exclusion and ventricle volumereduction to be applied at any appropriate time during the course of thedisease. Rather than merely awaiting foreseeable disease progression andattempting to alleviate existing cardiac dysfunction, the techniquesdescribed herein may be applied proactively to prevent some or all ofthe heart failure symptoms, as well as to reverse at least a portion ofany existing congestive heart failure effects, to limit or halt theprogression of congestive heart failure, and/or to retard or preventcongestive heart failure disease progression in the future. Someembodiments may, for appropriate patients, limit the impact ofmyocardial infarction scar formation before heart failure everydevelops.

Referring now to the schematic illustration of FIG. 2, a side view of alower portion of the heart H schematically illustrates how a size of thechamber of the heart can be limited using a plurality of implants.Implants 12 extend through the left ventricle (through the plane ofillustration) so that only anchors of the implants are visible on theepicardial surface of the heart. By using a plurality of laterallyoffset anchors 12, a left ventricle LV is reduced from an initial sizeto a smaller effective size by engagement between the inner surfaces ofthe septum and left ventricle wall. A region of engagement 14 betweenthese endocardial surfaces extends between the implants 12 andeffectively excludes scar tissue along the lower portion of the septumand/or left ventricular wall from the functioning left ventricle. Byarranging the implants 12 across some or all of the left ventricle, theremaining contractile tissue of the ventricle can make effective use ofthe reduced chamber volume to provide more effective pumping of theblood from within the heart, and may also avoid excessive stagnant voidsthat remain in fluid communication with the blood flow that mightotherwise collect and release thrombus.

Referring now to FIGS. 2A and 2B, a schematic top view shows threelaterally offset implants 42 that can be used to, in combination,effectively exclude scar tissue from left ventricle LV. In theillustration of FIG. 2A, each implant is shown in an elongateconfiguration. More specifically, each implant 42 extends distally froman associated deployment catheter 46 to a distal left ventricular wallanchor 50. A septal anchor 48 is coupled to the wall anchor 50 by atension member 52. The tension member 52 of the implants 42 are offsetlaterally, with the tension members here shown extending roughlyparallel to each other across the left ventricle LV. In otherembodiments, the tension members may be disposed at an angle relative toeach other, and may even extend across each other. Nonetheless, bypositioning the anchors laterally offset of each other, effectiveexclusion of scar tissue from the left ventricle LV may be enhanced.

Referring now to FIG. 2B, implants 42 are shown fully deployed, withdeployment catheters 46 detached from the implants and removed from theheart, and tension members 52 axially shortened from the elongateconfiguration of FIG. 2A to a shortened, tensioned configuration.Implants 42 in the shortened configuration draw endocardial surfaces ofthe wall W into engagement with the corresponding endocardial surfacesof septum S sufficiently to effectively exclude at least a portion ofthe scar tissue from the functioning lower ventricle. Note that theengagement need not be absolute along the entire cross section of thelower ventricle, so long as scar tissue is effectively excludedimmediately after the procedure or, after an initial tissue response tothe implant(s), at least some of the scar tissue is not subjected to thestress of being included in the pumping left ventricle. This may improvepumping efficiency of the remaining left ventricle and may limit diseaseprogression from enlarged heart wall tissue stresses.

Referring now to FIGS. 2C and 2D, alternative implants 42′ may alsoinclude a septal anchor 48 and a wall anchor 50, with a tension member52 extending therebetween. Such alternative implants may, in some cases,have multiple wall anchors 50 associated with each septal anchor 48, ormultiple septal anchors associated with each wall anchor. The tensionmembers 52 may extend in positions that are both angularly and laterallyoffset from each other. As shown in FIG. 2D, axial shortening of thetension members between the anchors 48, 50 may leave a portion of thetension member extending into the extra-cardiac space. In someembodiments, one or a plurality of implants may provide a bunchingengagement of endocardial tissues, with the engagement extending uponmultiple fold lines so as to effectively exclude at least a portion ofthe scar tissue. Some or all of the components of the implants may bepositioned using an epicardial access approach, with or withoutendocardial delivery or deployment catheters 46 (see FIG. 2A) for otherimplant components.

Referring now to FIGS. 3A and 3B, deployment of the implants describedherein and implementation of the therapies will benefit from accurateand reliable identification of the margins separating the scar andviable, contractile myocardium. Such identification can be accomplished,for example, using pre-operative imaging, catheter-sensed activationpotentials, pacing thresholds, ultrasonic imaging characteristics,biomarkers, or a variety of other tissue imaging and/or characterizationmethodologies. In general, it will be beneficial to provide informationto the physician deploying the system to allow accurate characterizationof selected locations as substantially comprising scar tissue orsubstantially comprising a viable contractile tissue. Additionally, thegeometry of the chambers of the heart, and particularly the leftventricular chamber, should be clearly imaged to facilitate the desiredreduction in size of the left ventricular chamber. This imaging may beaccomplished by one imaging modality or by a combination of differentimaging modalities. Exemplary imaging modalities which may be employedfor identification of the heart geometry and/or tissue characterizationinclude: echocardiography (including intracardiac echocardiography(“ICE”) and/or extra-cardiac echocardiography (such as transesophagealechocardiography and/or transthoracic echocardiography (“TTE” and “TEE”,respectively) or the like), intra- or extra-vascular endoscopy,fluoroscopy, or any of a variety of alternative existing or new imagingtechniques, either alone or in combination.

FIGS. 3A and 3B illustrate an example of ICE showing the geometry of theheart chambers, including a right atrium RA, a portion of the rightventricle RV, and the left ventricle LV along with some of the hearttissues bordering these chambers. FIG. 3B illustrates an intracardiacechocardiography image in which a catheter device within the ventriclecan be seen.

Deployment of the structures described herein may also benefit fromsensors that can be used to monitor the procedure, such sensors ideallyproviding a real-time assessment of the progress of the treatment andperformance of the heart during deployment and/or as deployment iscompleted. The goal of deployment will often be to achieve a desiredreduction in size of a chamber (typically the left ventricle), whileavoiding overcorrection (which might otherwise induce acute diastolicdysfunction). Such functional assessment sensors may comprise pressuresensors, hemodynamic sensing systems, strain sensors, oxygen saturationsensors, biological marker detectors, and/or other sensors measuringheart function to permit a quantitative assessment of efficacy of theprocedure as it is implemented.

Referring now to FIGS. 4A-4E, exemplary techniques and structures foraccessing and penetrating the septum and left ventricular wall can beunderstood. First summarizing these steps, it will be advantageous toidentify, engage, and temporarily hold the device in alignment with adesired position on the right ventricular septum, as schematicallyillustrated in FIG. 4A. Identification or characterization of theengaged tissue will also be advantageous. The septum will be penetratedas can be understood with reference to FIG. 4B, and the system issteered across the left ventricular chamber as illustrated in FIG. 4C.The system engages one or more target locations on the left ventricularwall as shown in FIG. 4D. The engaged tissue may be characterized andthe system repositioned as needed, with the system being held inengagement with the left ventricular wall if found to be at anappropriate or designated position, with the system optionally attachingor temporarily affixing itself to the left ventricular wall. The leftventricular wall may then be perforated, penetrated, or otherwisetranscended as illustrated in FIG. 4E. As indicated above regardingFIGS. 3A and 3B, target tissue access, penetration, and implantdeployment may be performed with reference to ICE within the bloodstream of the vascular system, with the ICE images typically comprising2-D sector images, the sectors often comprising an about 60 degreesector.

In more detail, referring now to FIG. 4A, an access and deploymentsystem 70 includes a catheter 72 and a penetrating/sensing perforationdevice 74. In some embodiments, separate probes may be used forpenetrating the heart tissues and characterizing the tissues. Here,catheter 72 accesses the right ventricle RV in a conventional manner,typically by advancing the catheter over a coronary access guidewire. Adistal end of catheter 72 is aligned with a candidate location along theright ventricular surface of the septum S by a combination of axialrotation of the catheter and distal/proximal positioning of thecatheter, as shown by the arrows. Positioning of the catheter isdirected with reference to imaging (as described above) and when the endof the catheter is aligned with the candidate location a perforationdevice 74 is advanced distally so that a distal end of the perforationdevice contacts the septum S.

Perforation device 74 may characterize or verify that the candidatelocation is appropriate, for example, by determining a pacing thresholdat the candidate site. Scar tissue ST may have a pacing threshold whichdiffers sufficiently from a viable tissue VT to allow the physician toverify that the candidate site comprises scar tissue and/or is otherwisesuitable. If the candidate site is not suitable, the perforation device74 may be withdrawn proximally to disengage the perforation device fromthe septum S, and the catheter may be repositioned as described above toa new candidate site.

Catheter 72 may comprise a commercially available steerable sheath orintroducer. Deflection of catheter 72 may be effected using one or morepull wires extending axially within the catheter body. Suitableintroducers include devices that can be introduced transcutaneously intoa vein or artery. Suitable steerable sheaths may generally comprise atubular catheter body with an open working lumen. The open lumen can beused as a conduit for passing another catheter into the patient body, orfor introducing another device (such as a pacing lead) into the patientbody. Exemplary steerable sheaths for use in system 70 may include thosecommercially available from the Diag division of the St. JudeCorporation, from Medtronic, from Bard, and/or from others. Preferably,the working lumen of catheter 72 will be in a range from about 5 F-11 F.Alternative systems may employ a flexible sheath removably receiving asteerable catheter or other device therein, the steerable catheteroptionally comprising a steerable electrophysiology catheter or a devicederived therefrom. Still further embodiments may employ pre-bent cardiacaccess catheters.

Regarding perforating device 74, one embodiment would comprise adeflectable or steerable catheter body (ideally comprising a 2 F-3 Fcatheter) with a metallic rounded and/or bullet-shaped electrode at itsdistal end. The distal electrode is connected to a signal wire thatterminates in a connector outside the body. Electrogram amplitudesrecorded from the distal electrode can be used to help determine if thedistal tip is located over scar tissue or over viable tissue. Efficacyin characterization of engaged heart tissues (between scar tissue andviable heart tissue) may be enhanced by recording the differentialsignal between the tip electrode and a band electrode located less than1 cm from the distal electrode.

Pacing from the distal tip can be employed to help avoid perforationthrough viable myocardium. For most patients, such a perforation sitewould be counter-indicated. If the heart can be paced from the tip usinga 10V amplitude pacing pulse, then viable myocardium will generally bedisposed within about 5 mm of the tip. When the proper penetration sitehas been identified, then the distal tip is electrically coupled to anelectrosurgical power source unit, and penetration is enabled byapplying power to the tip in cut mode. At proper power settings, thisperforation method can allow a clean perforation channel to be createdwithout the tearing that can otherwise occur with physical perforationof the septum or free wall.

Once an appropriate site has been identified and verified, the system isheld in alignment with the candidate site, and may optionally be affixedtemporarily at the verified site. Perforation device 74 is advanceddistally into and through septum S as illustrated in FIGS. 4B and 4C.Perforation device 74 may have a sharpened distal tip, a rotatablehelical or screw structure, or other mechanical attributes to facilitatepenetration into and perforation through the myocardium. Energy deliveryelements (such as electrosurgical energy, laser energy, or the like) mayalso be provided. In some embodiments, system 70 may employ componentssimilar to or modified from known septum traversing systems used foraccessing the left ventricle. In general, it may be advantageous to seekto perforate tissue with an axis of perforation device 74 orientedacross the ventricle and straight toward or near a suitable target sitefor the subsequent perforation, as imposing excessively acute angles onthe heart tissue may weaken or even tear the heart tissue.

As can be understood with reference to FIGS. 4C and 4D, once perforationdevice 74 has penetrated through the septum S, manipulation of thecatheter 72 under the guidance of the imaging system allows theperforation device to be steered across the left ventricle LV and intoengagement with a target location along the wall of the left ventricle.The tissue at this target location may be characterized using a sensorof perforation device 74, pacing of the engaged tissue, or the like, andthe end of the perforation device repositioned as needed. The preferredlocation for deployment of the implant may be along or adjacent to scartissue ST. In some embodiments, system 70 may be used for positioning ofa lead at a location separated from the axis of the implant tensioningmember. System 70 also allows for epicardial lead placement by advancingthe perforation device 74 endocardially through septum S and themyocardium of the left ventricular wall W until it is located on theepicardial surface of the heart. The perforation device 74 and/or leadmay be at least temporarily fixed at that location and tested for properpacing effect, as can be understood with reference to FIGS. 4E and 5B.

The access and deployment system 70 described above with reference toFIGS. 4A-4E may be supplemented with or replaced by a number ofdiffering system components. For example, as can be understood withreference to FIG. 5A, a balloon catheter 80 or other sealing structuremay be used, optionally being advanced within catheter 72 and/or overperforation device 74. The balloon of balloon catheter 80 may bepositioned within the myocardium of septum S or the left ventricularfree-wall W to anchor the deployment system temporarily to the hearttissue and control blood loss, particularly blood loss through the leftventricular wall into the extra-cardiac space. In some embodiments, twoseparate balloons may be used to seal both the septum and the leftventricular wall. Balloons may also be used with or as anchors of theimplant device.

Still further alternative structures may be employed, perforation device74 may have any of a variety of sensors, including pressure sensors andthe like. System 70 will often comprise high contrast structures toenhance imaging, such as by including materials having highradio-opacity, echo-density, or the like. As noted above, perforationdevice 74 may have or be used with a cutting, drilling, or othermechanism to help in tissue penetration. Still further alternativestructures may be used for steering and positioning of the deploymentsystem and perforation device. For example, rather than manuallymanipulating or steering catheter 72 to position and orient the implant,the deployment system may employ robotic surgical techniques such asthose now being developed and/or commercialized for manipulation ofcatheters. Magnetic steering of the catheter end may also be employed,and any of a wide variety of mechanical steerable or pre-formed catheterstructures could be employed. Some or all of the components may accessthe left and/or right ventricular chambers using an epicardial approach,rather than the endovascular approach described above. A combination ofan extra-cardiac and intracardiac approach may also be employed, withthe components of the implant being introduced in any of a wide varietyof techniques. In some embodiments, implant 42 and/or other componentsof the system may be deployed in an open surgical procedure. Directlyaccessing at least the epicardial surface of the heart may significantlyfacilitate positioning and deployment of implant 42, particularly fordevelopment of implant system components and techniques, including thosewhich may later be deployed in a minimally invasive manner.

Referring now to FIGS. 5B and 6A-6C, implant 42 is deployed throughcatheter 72 of deployment system 70, with the implant initially beingdeployed in an elongate configuration extending across left ventricleLV. Anchors 48, 50 of implant 42 advance distally through a lumen ofcatheter 72 while the anchor is in a small profile configuration, asillustrated in FIG. 6A. Anchor 50 expands from the small profileconfiguration to a large profile configuration, which may be effected byaltering a distance between a distal end 82 and a shaft of tensionmember 52 using elongate bodies 84, 86 detachably coupled to the distalend 82 and tension member 52, respectively.

In general, anchors 48, 50 will be deployable through, over, or adjacentto the myocardium tissue penetrating components of deployment system 70.The anchors will attach to or otherwise engage the wall, usually byexpanding or inflating into a cross section larger than that of thepenetration through the heart tissue. A wide variety of anchorstructures may be employed, including structures that form a disk-shapedsurface or lateral extensions from an axis 90 of implant 42. As can beunderstood with reference to FIG. 60, an inflatable bladder 92 orballoon of appropriate shape may be used alone or in combination withother anchoring structures. If an inflatable bladder or balloon is used,it may be filled with a substance which is initially introduced as aliquid, but which reversibly or irreversibly solidifies. Suitable fillmaterials may, for example, comprise liquid silicone rubber, which canpolymerize at any of a variety of alternative desired rates depending onthe chemistry of the material used. Optionally, the material maysolidify over more than one hour, optionally over many hours or evendays at body temperatures. During a procedure, such an injected liquidcould be removed if desired, but the material would eventually solidify.Biological adhesives could also be delivered as fluid to fill a balloon,though cure times are relatively shorter for such materials. Suchmaterials would irreversibly solidify.

The septal and left ventricular wall anchors 48, 50 may be identical orsimilar in structure, or may differ to reflect the differences betweenthe epicardial and endocardial surfaces they engage. Fixation to thewall and septum will generally be sufficient to support the tension oftensile member 52, which will generally be capable of approximating thewall and septum, typically maintaining proximity or engagement betweenthese structures during beating of the heart. Anchors 48, 50 and tensilemember 52 will often comprise high-contrast materials to facilitateimaging, such as by including materials of sufficient radio-opacity,echo density, and the like.

In some embodiments, implant 42 may be used alone or with similarimplants to effect volume reduction over a length, width, or volume ofthe ventricular wall. When at least a portion of the implant 42 isdeployed using an epicardial approach, left ventricular anchor 50 willoften be included in the components attached from outside the heart,with tensile member 52 and/or anchor 48 being attached to thisepicardial component during deployment. Robotic structures may be usedto position the intracardiac or extra-cardiac components, and/or toattach the two of them together.

Referring again to FIGS. 6A-6D, the exemplary anchor structure comprisesa Nitinol™ shaped memory alloy or other flexible material formed into atubular shaft. Axial cuts 94 may be formed along this tubular shaft,with the cuts having a desired length and being disposed near distal end82. Anchor 50 is advanced until the most proximal margin of cuts 94extends clear of the heart tissue. A retraction member 96 (optionallybeing releasable attached to the associated elongate body 86) fixed tothe inside of distal end 82 is retracted proximally, expanding the wallsof the tubular shaft radially into the circumferential series of arms98. Tissue engaging surfaces 100 of arms 98 may be substantiallyperpendicular to axis 90 of the implant. Arms 98 may have two generalcomponents, including the portion of the arm along tissue engagingsurface 100 and a slightly longer bracing portion of the arm 102extending away from the tissue engaging surface along axis 90. Theproportionate sizes of these two elements of arms 98 may bepre-determined by localized altering of the arm stiffness (effecting theplacement of living hinges) or the tubing material will otherwisepreferably bend so that the arms assume a desired shape. The deployedarms may have, for example, the pyramid shape shown with the tissueengaging surface 100 supported by angled portions 102 with apyramid-like force distribution, the angled bracing portions forming atriangular relationship with the surface of the heart wall.

Member 96 may remain within the deployed anchor, axially affixingtensile member 52 relative to the end of the anchor after deployment ofthe implant. This can help inhibit collapse of the arms 98. In someembodiments, arms 98 may be biased to the large cross section deployedconfiguration, such as by appropriate treatments to a shape memory alloyor the like. In such embodiments, member 98 or some other actuationstructure may restrain the anchor in a small cross sectionconfiguration, it may not remain within the deployed implant after it isexpanded.

As can be understood with reference to FIG. 60, once the anchor 50 isdeployed and in position, additional support elements may be positionedor deployed through the deployment system 70. For example, a spaceoccupying or expandable structure such as bladder 92 may be positionedor inflated within arms 98, internal support structures (optionallycomprising internal pyramid-like support arms) may be deployed. Theseptal anchor 48 will optionally have a structure similar to anchor 50,with the proximal and distal orientations of the arm structuresreversed.

While anchor 50 of FIGS. 6A-6D is shown as being integrated into atubular shaft of elongate tensile member 52, the anchor or fixationdevice may alternatively comprise a separate element introducedseparately over a guidewire or the like. Still further alternatives maybe employed, including fixation of the heart walls by placement ofmagnetic materials on or within the walls, with the bodies acting asanchors and the magnetic material acting as a tensile component so as tohold the walls in apposition.

Anchors 48 and/or 50 may optionally be drug eluting. For example,bladder or balloon 92 may have a porous surface capable of eluting asubstance from the film material. Alternatively, an outer surface of theballoon or the anchor structure itself may comprise a permanent orbiodegradable polymer or the like, such as those that have beendeveloped for drug eluting stents and available from a number ofcommercial suppliers. Drugs eluted from the implants may include any ofthe compositions eluted from drug-eluting stents.

Referring now to FIGS. 5B, 7A, and 7B, after anchors 48-50 are deployed,implant 42 may be shortened from its elongate configuration with arelatively large distance between the anchors along tensile member 52 toa shortened configuration. In some embodiments, the tensile member maycomprise a shaft of the tissue penetrating perforation device 74 (seeFIGS. 4A-4E). In other embodiments, tensile member 52 will comprise aseparate structure. In many embodiments, the tensile member and anchorswill remain permanently in the heart to hold the septum and leftventricular wall in apposition. To allow shortening of the tensilemember, excess length of the tensile member may be removed with thecatheter 72 and other components of the delivery system, and/or someportion of the length of the tensile member may remain in theextra-cardiac space outside the left ventricular wall.

Optionally, a ratchet mechanism may couple the septal anchor 48 to thetensile member 52, with the ratchet mechanism allowing the separationdistance between the anchors to gradually decrease. While exemplaryratchet mechanisms are described below with reference to FIGS. 11A-11C,12A and B, and 14A-14C, a wide variety of alternative structures thatcan be reconfigured in situ to alter the separation distance between theanchors might alternatively be employed.

Referring now to FIG. 8, additional optional elements for the implantsand/or deployment systems described herein can be understood. Here, aguidewire 102 is shown extending through a perforation of leftventricular wall W, with components of the deployment system and/orimplant advanced over the guidewire. A deployment catheter sheath 104may be used with or without guidewire 102. Guidewire 102 and/or sheath104 may be steerable to facilitate access and deployment of the implant.

A temporary or permanent anchor is here provided by a balloon 106. Anaxially-oriented portion of the outer surface of balloon 106 engages theadjacent epicardial surface of wall W to pull the wall towardsengagement with the septum, as described above. Balloon anchor 106 maycomprise a structure similar to a balloon of a balloon catheter, with anexpandable and biocompatible bladder material defining the balloon wall.Along with the exemplary fill materials described above, the fillmaterial may generally comprise a reversibly or irreversibly hardenablepolymer, and the bladder material may have pores to allow eluting ofdrugs from the fill material or fluid.

An annular expandable structure such as annular balloon 108 on anassociated catheter 110 may expand within the myocardium from theperforation or penetration through the left ventricular wall W or septumS. Balloon 108 may help to temporarily hold the deployment system inposition relative to the perforation and tissue structures, or may insome embodiments be used as a permanent anchor (with or withoutadditional anchoring structures). Temporary deployment of balloon 108against the myocardial tissues may be particularly advantageous duringor after perforation of the free left ventricular wall W duringdeployment of the wall anchor, as it may help to limit the release ofblood into the extra-cardiac space. Balloon 108 may comprise arelatively standard balloon catheter material, such as nylon, PET, orthe like.

Yet another aspect schematically illustrated in FIG. 8 is a probe 112having a surface 114 that treats the endocardial surface of the leftventricle wall W or septum S so as to promote formation of adhesions.Surface 114 may comprise a bur or other mechanical energy applicationsurface for imposing mechanical trauma on the tissues within the heart.In alternative embodiments, surface 114 may comprise an electrodesurface for applying electrosurgical energy, light refracting surfacefor applying visible or invisible radiation, one or more agent deliveryports for transmitting caustic or sclerosing agents to the heart tissue,or the like. Such surfaces may apply a controlled, limited trauma to thetissue surface regions of the left ventricular wall and/or septum so asto induce the formation of scar tissues bridging these two tissuestructures and forming permanent adhesions therebetween.

When a probe 112 or surface of the implant or delivery catheter is usedto promote formations of adhesions, or when the implant providessufficient compressive force between the left ventricular wall andseptum so as to promote adhesions without separately imposing a traumaon the tissue surface, some or all of the implant may comprisebiodegradable material. After the adhesions are fully formed and thebiodegradable material of the implant degrades, the natural adhesionsmay alone maintain the reduced size of the left ventricle, exclude scartissue from the effective left ventricle, and limit the effects ofcongestive heart failure. Suitable biodegradable materials for use inthe structural components of the implants described herein may includematerials developed for and/or used in biodegradable stent structures.

While an myocardial engagement balloon 108, balloon anchor 106, andtrauma inducing probe 112, are shown schematically together in FIG. 8,and while some embodiments of the methods and systems described hereinmay make use of all three of these components, many embodiments mayemploy only any one or any two of these optional structures.Additionally, while much of the above-description relates tointravascular access and deployment of at least a portion of theimplant, other embodiments may be deployed during laparoscopic or evenopen heart surgery. Such embodiments may be particularly beneficial forverification and tailoring of the pattern of multiple implants to beused for scar tissue exclusion and left ventricular volume reduction,with subsequent embodiments making use of the verified and/or refinedpatterns through an at least partially intravascular approach.

Referring now to FIG. 9, embodiments of the invention may be deployedusing a subxiphoid incision SI to access the heart, and/or theventricles of the heart. In some embodiments, additional access may beobtained through one or more intercostals space for one or moreinstruments. As shown in FIG. 10, a double balloon catheter 120 mayoptionally be used to unload the heart tissue. Double balloon catheter120 can provide inflow occlusion to decompress the ventricles, therebyreducing the systolic pressure. This may aid in reducing the ventricularvolume and/or in the exclusion of dysfunctional cardiac tissue. Doubleballoon catheter 120 may optionally be placed using open chest surgery.Alternatively, double balloon catheter 120 may be positioned usingminimal invasive techniques, such as via a femoral or subclavian vesselsor veins, and optionally being positioned percutaneously.

In some embodiments, double balloon catheter 120 may be positioned sothat one balloon is in the superior vena cava and one balloon is in theinferior vena cava, thus blocking most or even essentially all bloodflow from the body back to the heart. It may be easier to insert theballoon catheter either into the jugular vein or the femoral vein thanit is to place using a cardiac insertion site. An alternative (and in atleast some cases faster) way of off-loading the left heart is to inflatea suitably large compliant balloon in the pulmonary artery just abovethe pulmonic valve (proximal to the branching into the left and rightpulmonary arteries). A partially inflated balloon will tend to floatinto the pulmonary artery from the right atrium, since blood flowcarries it into that position. Hence, this may provide another method ofdecreasing preload on the ventricle.

With reference to FIGS. 11A-11C, one variation of a transventricularimplant and anchor system deployment from a left ventricular LVapproach. A sharpened, curved tissue piercing tubular body 122 piercesthe left ventricular wall, the septum, and extends back out through theright ventricular wall. This allows a ratcheted tension member 124 to beintroduced through the tissues of the heart within a lumen of tubularbody 122, with a first anchor 126 being attached to the tension memberafter insertion through the tubular body and expanded as described aboveor affixed after the distal end of the tension member extends free ofthe heart tissue. Regardless, once the tension member extends intoand/or through both ventricles, the tubular body 122 can be withdrawnproximally and a second anchor 128 can be moved distally along thetension member to engage the myocardial surface of the heart, as seen inFIG. 11B. Second anchor 128 may optionally pass through the lumen oftubular body 122 and expand radially, or may be coupled to tensionmember 124 after the tubular body is withdrawn.

An exemplary ratcheting interface between tension member 124 and secondanchor 128 may make use of a series of radial protrusions and/or detentsdisposed along an axis of the tension member. For example, the tensionmember may have slide surfaces which taper radially outwardly distallyalong the tension member to allow the anchor interface to slidesequentially over the slide surfaces in a distal direction, and detentsurfaces which are oriented distally to engage corresponding proximallyoriented surfaces of the anchor interface so as to inhibit proximalmovement of the anchor relative to the tension member. Second anchor 128may have a ratchet interface structure including (or derived from) thesealing components of a Touhy-Borst valve structure. Such an interfacemay resiliently deflect to pass the slide surfaces of the tension memberand may grab or engage the detent surface when the tension member ispulled distally. Such a valve structure may also be increased indiameter to release the tension member if desired and/or tightenedtowards its smallest diameter to immovably (and optionally permanently)affix the anchor relative to the tension member. Exemplary embodimentsof ratcheting tension member 122 may comprise polymers or metals,optionally comprising a polyester such as Mylar®, a thermoplastic suchas Nylon™, a stainless steel, a shape memory allow such as Nitinol™, orthe like.

As shown in FIG. 11C, second anchor 128 can be positioned along tensionmember 122 so as to effectively exclude scar tissue from the leftventricle and/or reduce a volume of the left ventricle. Some portion oftension member 122 may be disposed within the right ventricle, rightventricle scar tissue may be excluded, and/or the volume of the rightventricle may also be reduced. The tension member may be severed using ablade or the like as shown schematically, though some of the tensionmember may extend into the extracardiac space. In alternativeembodiments using different surgical approaches (such as when using thecatheter-based systems described above), at least a portion of thetension member may extend into the right ventricle or the like.

Referring now to FIGS. 12A and 12B, another alternative embodiment of animplant 130 and deployment system makes use of a transventricularapproach from the right ventricle. A curved tension member 132 having adistal tissue penetrating end 134 and a proximal anchor 136 affixedthereto is introduced through the wall of the right ventrical, throughthe septum, across the left ventricle LV, and out through the leftventricular wall. The tension member 132 and affixed anchor 136 areadvanced distally so that the anchor engages the surface of the heart,and a second anchor 138 is attached by passing distal end 134 throughthe anchor. Second anchor 138 is ratcheted proximally along tensionmember 132 to exclude scar tissue and limit a size of the leftventricle, with the distal end and at least a portion of the tensionmember that is distal of the positioned anchor being severed and removedfrom the deployed implant. FIG. 13 shows an expemplary double ballooncatheter for use as described above with reference to FIGS. 9 and 10.FIGS. 14A-14C schematically illustrate another transventricular anchorsystem and deployment from a surgical site outside the heart similar tothat of FIGS. 11A-11C, using a tubular body 142 to position a tensionmember 142 to which first and/or second anchors 146, 148 are ratchetablyaffixed.

It should be noted that the systems and methods described herein forexcluding scar tissue and reducing a size of a chamber of the heart maymake use of a plurality of different implants of different types andeven different surgical approaches. For example, while systems mayinclude a plurality of implants deployed from a site outside the heart(such as the embodiments shown in FIGS. 11A-11C, 12A and B, and14A-14C), alternative systems may include one or more implants of one ormore types deployed from outside the heart, along with one or moreimplants of one or more types deployed from inside the heart using ablood-vessel approach. Systems with a plurality of implants deployedfrom outside and/or inside the heart may benefit from any of a varietyof imaging techniques so that the implant systems effectively excludescar tissue and limit a size of one or more heart chamber.

While exemplary embodiments have been described in some detail forclarity of understanding and by way of example, a variety ofmodifications, adaptations, and changes will be obvious to those ofskill in the art. Hence, the scope of the invention is limited solely bythe appended claims.

1.-20. (canceled)
 21. A method for treating a heart, the heart having afirst chamber bordered by a septum and a wall, wherein the chambercomprises a left ventricle of the heart, the heart having a secondchamber separated from the first chamber by the septum, the methodcomprising: providing a perforation device having a distal tip that isconfigured to deliver electrosurgical energy to heart tissue to enablethe perforation device to penetrate through the heart tissue;penetrating, via the perforation device, the septum at a first locationselected for deployment of an implant; penetrating, via the perforationdevice, the wall at a second location selected for the deployment of theimplant; controllably steering the perforation device between the firstlocation and the second location; and deploying the implant by affixinga first anchor of the implant adjacent the penetration of the septum,affixing a second anchor of the implant adjacent the penetration of thewall, and applying tension between the first anchor and the secondanchor; wherein the tensioned members are tensioned sufficiently tobring the wall and septum into engagement, and thereby effectivelyexclude a region of the wall and septum from the left ventricle withscar tissue extending along the excluded region.
 22. The method of claim21, further comprising sensing a pressure from a distal end of theperforation device advancing through the heart tissue at the firstand/or second locations so as to characterize the tissue.
 23. The methodof claim 21, further comprising penetrating the wall at a plurality ofadditional locations, wherein a plurality of separate implants aredeployed, each deployed implant having a tension member extending from afirst anchor at an associated penetration of the septum to a secondanchor at an associated penetration of the wall so that the tensionmembers are laterally offset, wherein tension is applied between theseptum and the wall by the laterally offset tension members of theimplants such that the implants, in combination, extend the engagementacross a portion of the chamber sufficiently to exclude a plurality ofregions of the wall and septum from the left ventricle with scar tissueextending along the excluded regions.
 24. The method of claim 21,further comprising engaging tissue near the first location or the secondlocation with a probe prior to penetrating the heart tissue,characterizing the engaged tissue with the probe, and repositioning theprobe from the characterized tissue to the first location or the secondlocation for penetration.
 25. The method of claim 24, wherein theengaged tissue is characterized by pacing the engaged tissue with anelectrode of the probe.
 26. The method of claim 21, wherein the anchorsare affixed by radially expanding the anchors and engagingaxially-oriented surfaces of the anchors with tissue adjacent theperforations.
 27. The method of claim 21, wherein the electrosurgicalenergy that is delivered via the perforation device comprises electricalenergy or laser energy.
 28. The method of claim 21, further comprisinginducing adhesions between the wall and the septum by treating a regionof endocardium bordering the first chamber, wherein the adhesions areinduced to affix the septum and wall to each other.
 29. The method ofclaim 28, wherein treating the region of endocardium bordering the firstchamber comprises subjecting the region to mechanical injury.
 30. Themethod of claim 29, wherein the mechanical injury is subjected on theregion via application of electrical energy, laser energy, or an agentor compound.
 31. The method of claim 28, further comprising a probehaving a surface that treats the endocardium to promote formation ofadhesions on the heart tissue.
 32. The method of claim 31, wherein thesurface of the probe comprises: a mechanical energy application surfacefor imposing mechanical trauma; an electrode surface for applyingelectrosurgical energy; a light refracting surface for applying visibleor invisible radiation; or one or more agent delivery ports fortransmitting caustic or sclerosing agents.
 33. The method of claim 32,wherein the surface of the probe comprises a bur.
 34. The method ofclaim 28, wherein at least a portion of the implant biodegrades or isremoved so that the adhesions restrain a size of the first chamber andeffectively exclude scar tissue from the first chamber.
 35. The methodof claim 21, wherein the tension is applied between the anchors bydecreasing a length of a tension member extending between the anchors.36. The method of claim 35, wherein the decreasing length of the tensionmember between the anchors results in a portion of the tension memberextending through the wall and remaining in an extra-cardiac space. 37.The method of claim 21, further comprising inflating a balloon adjacentthe perforation of the wall so as to inhibit bloodflow through theperforation.
 38. The method of claim 21, wherein at least a portion ofthe implant is deployed by accessing the epicardial surface from outsidethe heart.
 39. The method of claim 21, further comprising capturing animage of the heart using at least one of intra cardiac echocardiography,extra cardiac echocardiography, endoscopy, or fluoroscopy, and whereinthe implant or delivery system components associated therewith providehigh-contrasts within the image.